Diabetes: the biography By Robert Tattersall. Oxford University Press, Oxford2009. 229pp. £12.99

Diabetes is an ancient disease, yet any understanding of its cause has evolved only since the late 19th century, while its treatment and that of its complications belongs exclusively to the 20th century, representing an extraordinary story of high-quality basic science and astute clinical observation.

The discovery of insulin in 1921 instantly changed a fatal disease into a chronic disease requiring lifelong treatment. The award of the Nobel prize to Frederick Banting and JJR Macleod (1923) for this achievement was followed by five further Nobel prizes during the subsequent decades. It was awarded to Bernardo Houssay (1947) for his work on the effect of pituitary hormones on insulin sensitivity; twice to Frederick Sanger (1958 and 1980) for his work on the structure of insulin; to Dorothy Hodgkin (1964) for elucidation of the crystalline structure of insulin; and to Rosalyn Yalow (1977) for studies on the immunogenic properties of insulin leading to methods for its immunoassay (and that of many other hormones). These achievements occurred almost simultaneously with remarkable clinical developments. Thus, foetal mortality in diabetic pregnancy, initially between 50% and 70%, was gradually reduced to less than 2%; mortality from diabetic ketoacidosis from 50% to a negligible percentage; and blindness, renal failure and amputation rates all decreased. The stories behind these achievements and many others must thrill both those with the condition and indeed any health professional.

The diversity of the mode of discoveries alone engenders the greatest interest. For example, the casual observation that sulphonamides caused hypoglycaemia yielded the development of sulphonylureas, still a mainstay of treatment for type 2 diabetes. Angiotensin-converting enzyme inhibitors which have alleviated the burden of nephropathy were developed from Brazilian viper venom; while photocoagulation to prevent blindness evolved from observing retinal burns occurring in people looking at the sun, and indeed the earliest clinical photo-coagulations used the sun as the light source for treatment.

Treatment disasters, however, were not unknown. The earliest sulphonylureas, carbutamide, caused several deaths, as did phenformin (from lactic acidosis), while troglitazone caused liver damage. The use of pituitary ablation in the treatment of proliferative retinopathy was a complete disaster causing both severe morbidity and death. The huge but seriously flawed University Group Diabetes Programme study (UGDP) during the 1960s incriminated tolbutamide as a cause of death, almost led to the extinction of sulphonylureas, and resulted in years of controversy.

Media exaggerations and distortion of events have throughout history led to false expectations by a gullible public, who ‘must have found it difficult to distinguish truth from fiction’. One newspaper hailed the discovery of insulin (1921) as a miracle with the headline ‘Certain diabetes cure… all difficulties overcome’. Again, following the major scientific achievement of manufacturing insulin of human configuration, the pharmaceutical industry advertised to doctors that it was ‘identical to the body's own insulin and therefore the logical choice’ – a very successful campaign without any evidence for the claim. The introduction of tablets for the treatment of type 2 diabetes led to newspapers creating ‘false hope that diabetes was now easy to control because tablets were available’. Fantasies continue to be published to this day, for example ‘Drinkable insulin breakthrough’, a headline published by the Scotsman as recently as 2002. It seems too much to ask for accurate, responsible reporting, even now.

Throughout this book, Robert Tattersall's understanding of patients' perceptions is palpable, no more so than when he observed that the innovation making the greatest difference to the lives of patients was not so much the introduction of human insulin, but the spread of diabetes specialist nurses. Diabetes led the way in the evolution of the specialist nurse as early as the 1950s, and most other specialties have followed suit since that time. Nurses both listen and provide ample consultation time which doctors might try to emulate and, indeed, Tattersall writes ‘that the doctor must have close acquaintance with his patient and give ample time to his problems’.

As a lifetime diabetologist, I thought I knew my history of diabetes pretty well. But this book skilfully brings to light many gems of information probably unknown to most of us. While the book is nicely produced, illustrations are few and of poor quality, the index perhaps deficient, but the glossary and extended reading list are excellent. Anyone interested in medical discoveries, lay or professional alike, would read it with pleasure.